Provider Demographics
NPI:1437467628
Name:MISSOURI VALLEY DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:MISSOURI VALLEY DENTAL GROUP, LLC
Other - Org Name:TIMBER RIDGE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-492-8300
Mailing Address - Street 1:11110 FORT ST STE 106&107
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-2183
Mailing Address - Country:US
Mailing Address - Phone:402-492-8300
Mailing Address - Fax:
Practice Address - Street 1:11110 FORT ST STE 106&107
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-2183
Practice Address - Country:US
Practice Address - Phone:402-492-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025876100Medicaid